Neuropathy: is opioid crisis diminishing access to pain management?

This physician, Dr. Thomas F. Kline, who used to be head of the Hospital in Home service at Harvard Medical School, thinks that it does so unnecessarily:

It appears that the new limits on opioid use will significantly impact people with chronic pain:(


So this is one of those huge debates – some will argue that opioids are not the best option for neuropathic pain anyway and that relying on them may actually prevent people from focusing on more effective long-term treatments for neuropathic pain. Personally, I’d go with a cannabinoid-receptor drug any day over an opioid for that.
Here’s a meta-analysis to that effect:

And a cannabinoid one:

Also, when it comes to chronic pain, most newer science suggests that using opioids isn’t a great option because it ultimately heightens pain sensitivity and lowers pain threshold.

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It’s not only a bane for neuropathy, it’s also one for short term pain.

As a prescriber I am almost made to feel like a criminal for prescribing hydrocodone for my patients. Not to mention the hoops I need to jump through to do so.

Our government is trying to cover up their own complicity in the illicit use of opioids and shifting the blame to prescribers. Again, a case of our government instead of doctors making treatment decisions for patients.

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I think the case for using it for surgical pain, though, is stronger than it is for neuropathic pain.
I don’t think doctors should have someone from DEA breathing over their shoulders preventing them from prescribing opioids. But*, I do think there should be a huge voluntary push from within each medical specialty to reduce the default use of them, and to change best practices on how they’re prescribed. For instance, after my C-section, I think they gave me a huge number of Vicodin pills that lasted a month.
I think it makes more sense for the standard to be for fewer pills at discharge, since only a small fraction of patients need that many. And I also think guidelines for non-pain specialties need to take a look at the newest evidence and not just default to opioids when in fact an NSAID or other medication might even be better.

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what do you mean the government’s complicity in the illicit use of opioids? Can you elaborate on that?

Yeah, as @TiaG notes, I’d lean away from opiate treatment for neuropathy for other reasons anyway—not generally that effective, lots of side effects, as well as habit forming. Gabapentin, SNRIs, TCAs etc, are better first-line treatments, and if it were me and those didn’t work, I’d probably then try a cannabinoid over an opiate. The issue is an important one for pain treatment more broadly though.

Here is a twitter comment from Dr. Kline, upon reading our post:

“Neuropathy is awful. I found opiates worked best – far less side effects than overly expensive lyrica working no better than generic dilantin.”

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I think stated my position ineloquently.

What I was alluding to is the way that government has a knee jerk response to drugs, making them less available to doctors and their patients.

As Dr. Kline stated, very few people who are prescribed opiates become addicted, yet many of these chronic pain patients still have pain. They are more likely in the absence of a medical prescription to attempt the procurement of drugs illegally to relieve their pain.

I’m sure that in many cases they don’t go out and buy hydrocodone, but they buy something stronger with higher addiction potential.

The bottom line is that I trust my doctors to do the right thing more than I trust my government to do the right thing.

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ah, ok. Somehow I thought you meant the government was selling heroin on the streets or part of some deliberate conspiracy to increase drug use.

I actually broadly agree with you because I generally think the War on Drugs and our entire approach to scheduled drugs has failed.

But I probably disagree on the extent to which overprescribing is a contributing factor to the opioid epidemic. While it’s likely true that “very few people who are prescribed opiates become addicted,” that may not be the relevant question. The true question is what fraction of people who do become addicted do so after a first exposure to a prescription medication, one prescribed either for them or others. So different prescribing habits could certainly change how often opiates get abused even if most people who are prescribed them do not abuse them.

Case in point: I got a bunch of Vicodin for my C-section, and when I didn’t need anymore, it just sat in my cabinet for years before I finally cleaned it out. If I had a teenager in the house, that could very easily have led to a problem. But if I was prescribed enough that very few or no pills remained, that scenario becomes less likely. Similarly, if someone who could get by with a non-additive drug is prescribed that first before an opiate, you eliminate the risk that either they or someone close to them will get hooked, even if the risk is small.

I don’t think the government should be mandating this – I think medical associations, journals, and those who change best practices in a field should get a lot more aggressive about highlighting this issue so that most doctors default to more stringent prescribing habits on their own.

Strongly disagree. Why are the people, the vast majority, deprived of adequate pain relief because of the few who will abuse it?

It goes along with a lot of product recalls. One person figures out a way to stupidly use a product and injure himself, so then nobody gets to use that product. People get hurt or fail for many reasons all the time. But why should I be deprived of something that will help me because someone else got hurt by it because it was misused?

Dr. Kline gave a very reasonable way to treat the situation, but it’s not likely to be accepted because it won’t fix the problem 100% of the time.